Reimbursement Fast Facts: Oxygen Concentrators

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Reimbursement Fast Facts: Oxygen Concentrators
Reimbursement Fast Facts: Oxygen Concentrators
This tool will assist you in understanding Medicare coding and coverage for oxygen concentrators.
Oxygen concentrators are medical devices that provide oxygen to assist patients with significant hypoxemia by taking room
air and concentrating it to a purity of 85% or greater. Oxygen concentrators may be categorized based on portability.
HCPCS
Code
Medicare CBR2
Medicare CBNE
Medicare CBNE
Recompete
Phase-in
July 1
Reimbursement* Reimbursement* Reimbursement*
Device
Description
Oxygen
concentrator
Oxygen concentrator
E1390
Single delivery port, capable of delivering
85% or greater oxygen concentration at
the prescribed flow rate
$70.00–$89.86
Non-rural:
$135.14–$140.56
Rural: $141.74
Non-rural:
$74.40–$81.46
Rural: $86.61
Portable
oxygen
concentrator
Portable oxygen concentrator, rental
$33.97–$42.00
Non-rural:
$46.69–$47.82
Rural: $49.27
Non-rural:
$36.41–$39.68
Rural: $42.16
E1392
*Oxygen’s 36-month capped rental payment amount includes the equipment, contents, supplies and accessories (i.e. cannula or mask, and tubing1)
Billing criteria for oxygen
Coverage criteria
Oxygen equipment is covered by Medicare for patients with
significant hypoxemia who meet the medical documentation,
laboratory evidence and health conditions specified in the
Medicare coverage requirements.2
Home oxygen therapy is reasonable and necessary only if all
of the following conditions are met:
Conditions for which oxygen therapy may be covered
include severe lung diseases (e.g. COPD, cystic fibrosis
and bronchiectasis), as well as hypoxia-related symptoms
expected to improve with oxygen therapy (e.g. pulmonary
hypertension, recurring congestive heart failure due to
chronic cor pulmonale, erythrocythemia and nocturnal
restlessness).
Coverage is also contingent upon documentation of qualified
blood gas studies (oximetry test or arterial blood gas test)
that meets the oxygen desaturation criteria (see next page).
Blood gas studies should be done while the patient is in a
chronic stable state.
1. The treating physician has determined that the beneficiary
has a severe lung disease or hypoxia-related symptoms that
might be expected to improve with oxygen therapy, and
2. The beneficiary’s blood gas study meets the criteria stated
below, and
3. The qualifying blood gas study was performed by a
physician, qualified provider or supplier of laboratory
services, and
4. The qualifying blood gas study was obtained under the
following conditions:
• If the qualifying blood gas study was performed during an
inpatient hospital stay, the reported test must be the one
obtained closest to, but no earlier than, 2 days prior to
the hospital discharge date, or
• If the qualifying blood gas study was performed outside
of an inpatient hospital stay, the reported test must be
performed while the beneficiary is in a chronic stable
state (i.e. not during a period of acute illness or an
exacerbation of their underlying disease), and
5. Alternative treatment measures have been tried or
considered and deemed clinically ineffective.
In this policy, the term “blood gas study” refers to either
an oximetry test or an arterial blood gas test.
Group I criteria include any of the following:
1. A
n arterial PO2 at or below 55 mm Hg, or an arterial oxygen
saturation at or below 88% taken at rest (awake), or
2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen
saturation at or below 88%, for at least 5 minutes, taken
during sleep for a beneficiary who demonstrates an arterial
PO2 at or above 56 mm Hg or an arterial oxygen saturation
at or above 89% while awake, or
3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in
arterial oxygen saturation more than 5% from baseline saturation,
for at least 5 minutes, taken during sleep associated with
symptoms (e.g. impairment of cognitive processes and
[nocturnal restlessness or insomnia]) or signs (e.g. cor pulmonale,
“P” pulmonale on EKG, documented pulmonary hypertension
and erythrocytosis) reasonably attributable to hypoxemia, (the
results must be at or below 88% or 55 mm Hg), or
4. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen
saturation at or below 88%, taken during exercise for a
beneficiary who demonstrates an arterial PO2 at or above
60 mm Hg or an arterial oxygen saturation at or above
90% during the day while at rest. In this case, oxygen is
provided for exercise if it is documented that the use of
oxygen improves the hypoxemia that was demonstrated
during exercise over the result recorded while the beneficiary
was exercising and breathing room air; a uniquely documented
result of exercise with O2 must be recorded in the medical
record. This is different than a recovery result.
Initial coverage for beneficiaries meeting Group I criteria is limited
to 12 months or the physician-specified length of need, whichever
is shorter. (Refer to the “documentation requirements” section
for information on recertification.)
Group II criteria include the presence of:
A. An arterial PO2 of 56–59 mm Hg, or an arterial blood oxygen
saturation of 89% at rest (awake), during sleep for at least
5 minutes or during exercise (as described under Group I
criteria), and
B. Any of the following:
1. Dependent edema suggesting congestive heart failure, or
2. Pulmonary hypertension or cor pulmonale, determined by
measurement of pulmonary artery pressure, gated blood
pool scan, echocardiogram or “P” pulmonale on EKG (P wave
greater than 3 mm in standard leads II, III or AVF), or
3. Erythrocythemia with a hematocrit greater than 56%
Initial coverage for beneficiaries meeting Group II criteria is
limited to 3 months or the physician-specified length of need,
whichever is shorter. (Refer to the “documentation requirements”
section for information on recertification.)
Group III includes beneficiaries with arterial PO2 levels at or
above 60 mm Hg or arterial blood oxygen saturations at or above
90%. Group III beneficiaries are generally not covered.3
Documentation requirements:
Documentation to support initial medical necessity
of oxygen may include:
•D
etailed Written Order or Certificate of Medical
Necessity (CMN) if sufficiently detailed and meets
signature,4 date and other requirements,5
•M
edical records that support the patient meets the
Local Coverage Determination (LCD)6 coverage and
payment requirements:
- Treating physician has determined the patient has
severe lung disease or hypoxia-related symptoms
that might be expected to improve with oxygen
therapy, and
- The patient’s most recent blood gas study met the
qualification criteria and was conducted by a qualified
professional, conducted during an inpatient stay or
conducted while the patient was in a chronic stable
state, and
- Treating physician evaluated the patient within
30 days prior to the date of initial certification, and
- Alternative treatment measures were tried or
considered, and deemed clinically ineffective
• Proof of Delivery7
Documentation for recertification to support
continued medical necessity of oxygen may include:
• Recertification CMN
•M
edical records documenting that the patient was
seen and re-evaluated by the treating physician
between the 61st–90th day for Group II or 90 days
prior to the date of the recertification for Group I8
•C
ontinued medical need for the equipment,
accessories and/or supplies is verified by:
-O
ne of the following documents dated within
12 months of the date of service under review:
A refill order, a change in prescription, a CMN
with appropriate length of need or medical record
showing use of the item
Documentation for Portable Oxygen Systems may
include:
•M
edical records supporting that the patient is mobile
within the home and the qualifying blood gas study
was performed while awake (at rest or during exercise)
Documentation for liter flow greater than 4 LPM
may include:
• A copy of the blood gas study showing blood gas levels
in the Group I or Group II range while the patient was
receiving oxygen at the rate of at least 4 LPM
Q &A
Q: When oxygen qualification testing is obtained from a
titration polysomnogram, is portable oxygen covered?
No, as with overnight oximetry, only stationary oxygen may
be justified based on titration polysomnography (PSG).
Q: What testing is required for patients with suspected
or known obstructive sleep apnea (OSA) to qualify for
home oxygen?
During qualification testing, the patient must be in a chronic
stable state, meaning obstructions need to be resolved
during testing. Therefore, an OSA patient must qualify
while they are awake or during a titration PSG conducted
at sleep. CGS has provided a helpful decision tree to
illustrate this point (see chart below).9
Q: What maintenance and servicing fees are applicable
to oxygen concentrators?
A maintenance and servicing fee of ~$70 is paid every
6 months, either beginning: 1) 6 months after the 36th
paid rental month, or 2) when the item is no longer
covered under the supplier’s or manufacturer’s warranty
(whichever is later). Only one maintenance and servicing
payment can be made for beneficiaries using both
stationary (E1390) and portable oxygen concentrators
(E1392). Note: Neither beneficiary-owned gaseous nor
liquid oxygen equipment (stationary or portable) is eligible
for maintenance and servicing payments.10 Service must
be performed and documented via a service ticket to bill
for maintenance fees.
Testing required for home oxygen qualification in beneficiaries with known or suspected OSA
1 Nov 2013
Known or
suspected
OSA
Oximetry while
awake?
Y
n
HST done?
n
PAP not covered
Y
n
Y
n
PSG done
Qualifying
result?
HST
diagnostic?
Y
n
Y
PSG
diagnostic?
PAP covered
Titration PSG
n
Y
Y
Hypoxic
after titration
n
Home oxygen
not covered
n
All testing must meet the requirements set out in the Medicare
LCDs for positive airway pressure (PAP) devices and oxygen
and oxygen equipment
Y
Home oxygen
covered
Q: What oxygen equipment is billable for contents post
36-month cap?
Only gaseous and liquid tank systems are eligible for
post 36-month cap content billing. Oxygen Concentrators
and Transfilling Equipment are not eligible for contents
payment.11
Oxygen equipment furnished
in month 36
Monthly contents payment
after the stationary cap
Oxygen Concentrator (E1390
or E1391)
None
Portable Gaseous or Liquid
Transfilling Equipment (K0738,
E1392 or E0433)
None
E0424 Stationary Gaseous
System
E0441 Stationary Gaseous
Contents
E0439 Stationary Liquid System
E0442 Stationary Liquid
Contents
E0431 Portable Gaseous
System
E0443 Portable Gaseous
Contents
E0434 Portable Liquid System
E0444 Portable Liquid Contents
Q: Do all oxygen items require a detailed written order
prior to delivery (DWOPD)?
No, the following items do not require a DWOPD:
oxygen concentrators (E1390 or E1391), portable oxygen
concentrators (E1392) and portable gaseous equipment
(K0738). While a DWOPD is not required for these specific
items, a detailed written order (DWO) is required prior
to billing and may be obtained prior to delivery when
possible. Note, the other items in the table above do
require a DWOPD.12
Q: How does payment change for patients who need more
than 4 LPM or less than 1 LPM?
If the beneficiary is prescribed both stationary and portable
gaseous oxygen at a rate that exceeds 4 LPM, suppliers
use the modifier “QF” to increase the monthly stationary
oxygen payment amount by 50%. If the prescribed amount
is less than 1 LPM, suppliers use the modifier “QE” to
decrease the monthly stationary oxygen payment amount
by 50%.13 When billing for higher liter flow reimbursement,
separate payment for portable O2 is not allowed.14
Q: Can oximetry data from ApneaLink™ Air or AirView™
(when an oximeter is connected to a positive airway
pressure device) be used to qualify a patient for
home oxygen?
No, patients with known or suspected OSA must
be tested in-person, either via an overnight titration
polysomnogram or via an awake in-person oximetry test.
All awake oximetry results must be obtained in-person
by a qualified medical professional with the exception of
overnight oximetry. Unsupervised or remotely supervised
awake home testing does not qualify as a valid test. For
beneficiaries with OSA, a qualifying oxygen saturation test
may only occur during a titration polysomnographic study
or during an in-person, supervised, awake test.6
1 MLN Matters (MM6297) Changes in Payment for Oxygen Equipment as a Result of the 2008 MIPPA and Additional Instructions Regarding Payment for DMEPOS; revised May 17, 2011 2 National Coverage Determination (NCD) for
Home Use of Oxygen (240.2) 3 Long-term Oxygen Treatment Trial (LOTT); NCT00692198 4 CMS Signature Requirements, April 22, 2010 5 Program Integrity Manual Chapter 3 Supplier Documentation 6 Local Coverage Determination (LCD):
Oxygen and Oxygen Equipment (L33797) 7 Oxygen and Oxygen Equipment Beneficiaries Meeting Group II criteria Documentation Checklist; CGS January 25, 2016 8 Oxygen and Oxygen Equipment Beneficiaries Meeting Group I criteria
Documentation Checklist; CGS January 25, 2016 9 Frequently Asked Questions: Oxygen Use in Beneficiaries with Obstructive Sleep Apnea (November 22, 2013) 10 MLN Matters (MM6792) Maintenance and Servicing Payment for Certain
Oxygen Equipment after July 1, 2010 11 MLN Matters (MM7416) Payment for Oxygen Contents 12 MLN Matters (MM8304) Detailed Written Orders and Face-to-Face Encounters; revised July 1, 2013 13 Payment rules found in the
“Medicare Claims Processing Manual,” Chapter 20 (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)), Section 130.6 (Billing for Oxygen and Oxygen Equipment) 14 Local Coverage Article: Oxygen and Oxygen
Equipment – Policy Article – Effective October 2015 (A52514)
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